Public Policy and Governance – Page 163

Reich’s Rules

What American politicians call privatization has been a focus of much my academic work.(If you go to the “Academic papers” section of this blog and search for privatization, you’ll find a lot of entries.)

I phrase it as “what American politicians call privatization” because–as Morton Marcus pointed out to me years ago– genuine privatization is what Margaret Thatcher did in England. She sold off government-owned assets like railroads and steel mills to the private sector, after which they were private. They paid taxes, and either prospered or failed, but government no longer had much to do with them.

What Americans call “privatization” is very different. The accurate term is “contracting out” –and it refers to the decision by government agencies to provide government services through for-profit or non-profit surrogates. That process should not be confused with procurement–no one expects city hall to manufacture its own computers or the myriad other items it requires in order to function. (Admittedly, the line can get blurry: contracting with a private paving company to fill potholes, for example. But few privatization critics are troubled by those long-standing practices.)

It is important to recognize that when a government agency contracts with a surrogate to provide services that the agency is legally required to provide, government remains legally responsible for the proper delivery of those services.

Robert Reich recently enumerated five rules that should govern these decisions. His rules are very similar to those on my class lecture on the subject. It should be obvious, for example, that government shouldn’t contract out when keeping a service in-house will be more efficient and cost-effective.

Other rules are less obvious, but no less important.

Don’t privatize when the purpose of the service is to bring us together – reinforcing our communities, helping us connect with one another across class and race, linking up Americans who’d otherwise be isolated or marginalized.

This is why we have a public postal service that serves everyone, even small rural communities where for-profit private carriers often won’t go. This is why we value public education and need to be very careful that charter schools and other forms of so-called school choice don’t end up dividing our children and our communities rather than pulling them together.

Don’t privatize when the people who are supposed to get the service have no power to complain when services are poor.

This is why for-profit prison corporations have proven again and again to violate the constitutional rights of prisoners, and why for-profit detention centers for refugee children at the border pose such grave risks.

Don’t privatize when those who are getting the service have no way to know they’re receiving poor quality.

The marketers of for-profit colleges, for example, have every incentive to exploit young people and their parents because the value of the degrees they’re offering can’t easily be known. Which is why non-profit colleges and universities have proven far more trustworthy.

Don’t privatize where for-profit corporations face insufficient competition to keep prices under control.

Giant for-profit defense contractors with power over how contracts are awarded generate notorious cost overruns because they’re accountable mainly to their shareholders, not to the public.

Perhaps the most troubling contracting practices involve the military; contract soldiers are uncomfortably similar to mercenaries, and the growing use of private companies in America’s various wars and military actions generates a number of very thorny issues, a topic I’ve explored elsewhere.

One of America’s many overdue conversations should address what services we expect our various levels of government to provide and the nature and extent of the evidence needed to support a decision to outsource service delivery.

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About Those Right-Wing Judges…

As most of you know by now, a conservative judge in Texas struck down the entire Affordable Care Act, ruling it unconstitutional.

The decision is a reminder that when judges are appointed on the basis of party loyalty rather than legal acumen, the results can hurt a lot of innocent people.

Legal scholars who have reviewed the decision believe it is badly flawed and will be overturned, but Daily Kos recently enumerated the consequences should it be upheld.

The most obvious loss would be that part of the law that forbids insurance companies from excluding coverage of pre-existing conditions. But as the author noted, if the law were really to disappear, that’s just a part of what would be lost.

As many as 17 million people could lose their coverage in a single year. The 15 million people covered under Medicaid expansion could lose their coverage. The improvements to Medicare that have saved the program billions of dollars—and reduced prescription drug costs for seniors—would be erased. Young people wouldn’t be able to stay on their parents’ insurance until they’re 26. The ban on annual and lifetime caps would be gone, and medical bankruptcies would escalate. Having lady parts would again cost women more than men, and being over age 50 would cost everyone more again. Limits on out-of-pocket costs would be gone. The tax credits that 9 million people are receiving to help them pay premiums would be gone.

The post focused on the political fallout of the threatened losses. (Even Republicans concede that the issue hurts them.) But the real lessons aren’t partisan.

There are two obvious “take-aways” here.

First is the incredible amount of damage that can be done by elevating ideologues to the bench. This sort of “smash and burn” judging is a direct result of viewing the federal courts as a partisan political prize rather than a constitutional safeguard to be protected by the appointment of dispassionate, knowledgable and qualified legal scholars.

The second is equally obvious. As important as the ACA is, as much of a step forward that it represents, it falls far short of what Americans need and most other wealthy countries have long had. Not only is it vulnerable to the sort of judicial assassination we’ve just experienced, it is simply insufficient.

It would be poetic justice–not to mention actual justice–if this effort by a radical judge prompted Congress to pass Medicare for All, or at least a “public option” allowing citizens of all ages to “opt in” to the program.

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Is This As Stupid And Worthless As It Looks?

There is a new federal rule requiring all hospitals to post a master list of prices online–enumerating the services they provide together with their prices, so that people can review them, and presumably “shop” for the best deal.

Think about that for a minute, then review the fine print on your health insurance, assuming you are fortunate enough to have health insurance. You will note that you have very little choice of what your insurer calls “provider networks.”

Think, too, about the last time you or someone in your family had a medical emergency. If you fell off a ladder, were in an auto accident, were having a heart attack or found yourself in any of a number of similar situations, your most urgent task was getting to the nearest hospital as soon as possible; I’m pretty confident you didn’t delay in order to review and compare hospitals’ charges.

There are other reasons to file this new requirement under “worthless.” Hospitals in America’s ridiculous healthcare industry don’t charge every patient the same price for the same service. Patients with insurance are actually charged less than those without, for one thing. For another, most hospitals don’t even have a good idea of what their services cost them to provide.

Some years ago, we had friends over for dinner; one of them was, at that time, vice-president of a local hospital, and I asked him to explain the infamous five-dollar aspirin. We’ve all seen those itemized bills after emergency room visits or hospital stays that include bizarre and frequently outrageous charges, including per pill pricing that vastly exceeds what the same pill would cost at the local drugstore.

Our friend’s response was honest, if not reassuring. Because hospitals must deal with multiple insurers as well as Medicare and Medicaid reimbursement rates and with uninsured patients, they engage in “innovative” and “creative” cost-accounting. In other words (although he didn’t put it quite this way), they play games with individual bills, depending upon the likely source and timing of payment.

The bottom line: unless things have changed rather dramatically since that dinner party, hospitals really don’t know what any given service actually costs them, and there is no “standard charge” for a given medical procedure.

As I have said many times, I am a believer in markets–in economic areas where markets can work. If I set out to buy a widget, I’ll shop around to see who makes the best widget for the best price. The market for widgets works, because it provides what is essential to a market transaction: a willing buyer and a willing seller, both of whom are in possession of all information relevant to the transaction.

I know what sort of widget I want, and pricing information–what widgets are going for–is easily available. The guy selling me that widget knows what his widget cost to manufacture, and how much he needs to get for it.

If I have a stomach ache, or measles, or a broken arm; if I am having a heart attack, all I know is that I need medical care. I don’t know what medical science has to say about appropriate medications and their dangers (I may not even know my diagnosis); I have no idea what my treatment options might be, which ones are least likely to manifest side effects, or what they should cost. I’m not even a “willing” buyer who can walk away if I think the price is too high. I lack the knowledge to evaluate the quality of the care I’m receiving, let alone the ability to walk away if I think that quality is substandard.

Markets simply don’t work in these situations, and knowing that a hospital has posted its “best guess” prices is irrelevant.

Every other advanced country has figured this out. I’m beginning to think that “American Exceptionalism” means “exceptionally dense.”

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Who Decides?

I’m a big fan of “connecting the dots.” Too often, We The People and the lawmakers we elect fail to recognize important connections; we treat issues in isolation, and often don’t understand why our “fixes” to those problems don’t work.

In all fairness, the connections are often obscure.

Recently, the Executive Director of In the Public Interest pointed out a connection that I had totally missed, even though I study both privatization and democratic processes. He warned that privatization is part of the ongoing assault on democracy.

“It couldn’t be clearer that the fundamental democratic right to have our voices — and votes — heard is under attack. Just this week, Wisconsin’s Republican-dominated legislature slashed early voting…in the middle of the night…during a lame duck session. Bottom line: there are politicians, conservative think tanks, and corporate funders who don’t want people to be able to vote. But we’ve learned through our work that there’s another — and perhaps deeper — threat to democracy spreading nationwide, and that is privatization. When corporations take control of public goods like water, transit, and schools, we give them the ability to make decisions that should be made democratically by us, the public.”

I often tell my students that the Bill of Rights, properly understood, is America’s answer to a foundational governance question: who gets to decide? Who decides what political opinion you hold, what prayer you say (or whether you pray at all), what book you read, how many children you have, who you are permitted to publicly love?

The Bill of Rights answers those and other questions by affirming the individual’s right to make those decisions for him/herself, by guaranteeing that we each have a significant measure of personal autonomy (otherwise known as self-government). Liberty, to the Founders, meant limiting the power of government to dictate what the Supreme Court has called the “intimate” decisions of its citizens.

Democratic theory is less prescriptive than the Bill of Rights, but it rests on the assumption that citizens’ assent to important aspects of their governance is a necessary element. Politicians and political scientists can and do disagree on just what those decisions are, about what decisions must be made by the citizens in order for a system to be considered democratic, but there is unanimity on the principle that “the people” must have the final say on the issues that are properly before them.

When government contracts out, it is authorizing a private entity to make decisions relevant to the contracted function. In many cases, that’s not a problem. (Leaving the decision about how much asphalt should be put in a pothole is hardly an assault on democracy.) When government turns over control of public goods like water, transit, and especially schools, that’s a different matter, and much more troubling.

Most of the considerable criticism of privatization has revolved around management issues, cost accounting, and occasionally corruption and “pay to play.” I’ve raised constitutional concerns as well.

I think we need to add the effect on democracy to the list. Have we turned over to private enterprise an area of decision-making that ought rightfully be democratically decided? What are those areas? And what are the dangers of contracting them away?

The answers will vary, but we need to ask the questions.

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When We Don’t Ask The Right Questions….

According to Engineering News Record (yes, I know I read a lot of weird shit–blame this one on my spouse, who subscribes),

A congressionally mandated study is recommending a dramatic increase in current highway spending to launch an ambitious new program to upgrade and modernize the aging, sometimes congested, Interstate Highway System. The report also calls for a hike in the federal gas tax to help pay for the plan.

It’s hard to fault this conclusion; the Interstate Highway System, like most of America’s infrastructure, is in indefensible disrepair. But looking at only one element of an integrated transportation system is like blaming all the dysfunctions of our broken government on Trump, without reference to the broken political system that facilitated his emergence and election. (Yes, we need to “fix” the Presidency by getting rid of the current occupant ASAP, but we also need to address gerrymandering, vote suppression, the Electoral College, the filibuster…)

Transportation, like so much else in our rapidly changing world, is undergoing all sorts of changes. A report that focuses only on highways (and not all highways, at that) without considering the present and future operation of the entire transportation system– air, rail (freight & passenger), state roads, etc.–misses much of the picture.

What sorts of transportation should policies promote? (For that matter, have any policies demonstrated the ability to shift those preferences? How? And which ones?)

What would the evidence tell us if we were asking the right (systemic) questions? What are the relative costs and benefits of shipping goods via rail versus truck, for example? (Data I’ve seen would suggest that we put more money into rail.) How do different modes of transit affect the environment? Which transportation methods are most energy efficient? What is the return on investment of repairs to highways versus repairs and upgrades to rail and air?

I am definitely not suggesting that we allow our Interstates to fall into further disrepair while we debate our approach to a more rational transportation policy, but America has a tendency to pay for mansions where cabins are all we need, especially when policymakers are hiring private contractors who can be expected to return the favor and support those policymakers when the next election comes around.

When lots of money has been spent on something, there’s a natural incentive to use it. (Ask any woman who bought an expensive dress that she subsequently realizes was a mistake.) It’s human nature to look for reasons justifying the original decisions–and to ignore alternatives that might be more cost-effective , convenient or make more economic sense.

If we want to base policy on sound evidence (which I’m not at all sure we do…),if we want good data gathered from sound research to inform our decision-making, it helps to start by asking the right question.

We desperately need a comprehensive analysis of America’s infrastructure. All of it.

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